Showing papers in "Acta medica Croatica : c̆asopis Hravatske akademije medicinskih znanosti in 2008"

[Needle aspiration cytology of the breast: current perspective on the role in diagnosis and management].

Abstract: The aim of this review is to highlight the continuing role of fine needle aspiration cytology (FNAC) in the diagnosis of breast lesions, against a background of its diminishing use in some centres, particularly those involved in breast screening, because of its controversial inadequate rate and suboptimal accuracy. This review explores the current practice and confirms the continuing role of FNAC in the diagnosis and management of breast lesions. The three main areas where FNAC still plays a major role are the following: (a) diagnosis of benign disease in symptomatic palpable lumps as part of triple assessment; (b) staging of breast carcinoma, in particular preoperative axillary lymph node FNAC and intraoperative sentinel node imprints; and (c) diagnosis of metastatic disease at distant sites following treatment for carcinoma. Excision biopsy of the lesion to establish whether it is benign or malignant is not an acceptable mode of diagnosis any more. When triple assessment is concordant, final treatment may be ensued without open biopsy. Triple assessment is a cost effective, easy to perform and time saving approach, however, it can only be used at those institutions where excellent imaging facilities as well as services of a cytopathologist are available. The majority of European countries use similar reporting system for breast FNAC (C1-C5), in keeping with European guidelines for quality assurance in breast cancer screening and diagnosis. A clear reporting system ensures that an unequivocal cytological diagnosis of malignancy is reliable, and in cases where mammography/ultrasonography and clinical examination are in agreement with FNAC, frozen section examination is unnecessary. Suggested thresholds for cytology performance (where therapy is partially based on FNAC) according to the UK NHSBSP are the following: absolute sensitivity (C5 only) >70%, complete sensitivity (C3, C4, C5) >90%, specificity >65%, positive predictive value >99%, false negative <4%, false positive <0.5%, inadequate rate <15%, inadequate rate from cancers <5% and suspicious rate <15%. The issue of optimal sampling to obtain adequate cell material in sufficient quantity is of paramount importance when assessing the accuracy of FNAC. The inadequate rates in FNAC from different sources are lowest when FNAC is performed by a cytopathologist and highest when done by a non-cytopathologist. The multidisciplinary approach is necessary to amplify FNAC quality and to reduce its diagnostic limits. Only when this model of activity is not available, the role of FNAC is less effective and the addition of core biopsy (CB) to FNAC should be considered. CB as an alternative diagnostic modality should be used advisedly, in situations where it is more likely to yield diagnostic information, e.g., in the diagnosis of impalpable masses, microcalcifications or a clinically apparent malignancy where preoperative chemotherapy is planned. CB should not be used as a substitute for poor performance at FNAC. The methods are not mutually exclusive. Where there is access to skilled cytopathologists, FNAC and CB can complement each other and provide a highly accurate, rapid and cost-effective means of patient triage. FNAC has an advantage of being an immediate and excellent method for on-site examination and one-stop diagnosis at breast outpatient clinics. Since the majority of patients attending a breast clinic have benign disease, they benefit from rapid diagnosis and discharge from the clinic. Sentinel node biopsy, now used routinely during the operation for breast carcinoma with the aim of achieving "one-step" surgery can be reduced by one third of patients who ultimately require axillary node dissection if preoperative image guided FNAC of the axilla is used. Positive intraoperative imprint cytology is a reliable tool for proceeding to axillary node dissection, the method having a very high specificity in all published series. FNAC remains the method of choice of diagnosing metastatic disease at extramammary sites. Hormone receptor status, but not HER 2, can be reliably assessed from cytological material. Cells carry a promise of molecular diagnosis and targeted treatment in the future. The future of breast FNAC is bright.

Cytomegalovirus infection in renal transplant recipients

Abstract: Cytomegalovirus (CMV) belongs to the family of human herpes viruses. It is also known as the human herpes virus 5 (HHV-5). In immunocompromised host it becomes significant pathogen, causing the spectrum of different symptoms and affecting different tissues and organs. Epidemiologic forms of CMV infection include primary infection, reactivation or secondary infection, and superinfection or reinfection. CMV infection has direct and indirect effects. Direct effects occur at the time of highest viraemia with severe clinical presentation. To the contrast, indirect effects occur at the time of asymptomatic viraemia as the consequence of immunologic response. Indirect effects are mediated by cytokines, chemokines and growth factors. Diagnosis of CMV infection is based on virus detection in body fluids and tissues. There are several diagnostic methods for detection of CMV, and their use is primarily determined by the possibilities of the specific transplantation center. Regarding the risk of CMV infection, several categories of renal transplant recipients may be identified. The main factor for estimation of risk for development of CMV infection is donor and recipient serological status. The highest risk is associated with combination of CMV seropositive donor and CMV seronegative recipient (D+/R-). CMV infection was often fatal before introduction of potent antiviral drugs in therapeutic protocols. Contemporary treatment has significantly decreased mortality rate from the CMV infection. Several drugs are used for prevention and treatment of CMV infection: hyper immune gamma globulin, gancyclovir, valgancyclovir, valacyclovir and acyclovir, depending on the kind of treatment (prophylaxis or preemptive treatment). In the case of CMV disease, the best results may currently be achieved with the combination of hyper immune gamma globulin and intravenous gancyclovir.

[Acute rhabdomyolysis: a case report and literature review]

Abstract: Acute rhabdomyolysis is a syndrome characterized by the lesion of skeletal muscle resulting in subsequent release of intracellular contents into the circulatory system, which can cause potentially lethal complications. These contents include myoglobin, creatine phosphokinase, potassium, aldolase, lactate dehydrogenase and glutamic-oxaloacetic transaminase. There are numerous causes that can lead to acute rhabdomyolysis and many of patients present with multiple causes. The most common potentially lethal complication of rhabdomyoloysis is acute renal failure. In this article we present a case of a patient that developed clinical signs of acute rhabdomyolysis after consumption of heroin and alcohol. After approximately nine hours of alcohol and heroin induced coma he had acute compartment syndrome of the right arm, and clinical and laboratory signs of acute rhabdomyolysis with acute renal failure as a complication of rhabdomyolysis. Acute rhabdomyolysis developed in the patient as the result of acute compartment syndrome, with direct toxic activity of alcohol and diamorphine. During the period of coma, due to lying in particular position over a long period of time, pressure upon the certain part of the body caused muscle compression and capillary occlusion in fascial compartments, which led to ischemia. Upon pressure relief and beginning of tissue recovery, post ischemic compartment syndrome occurred with subsequent rhabdomyolysis. Getting out of coma the patient started to complain of severe pain in the right arm, which clinically worsened on passive stretching of the limb, with the loss of sensation and weakness. Laboratory findings showed high levels of creatine phosphokinase as the most sensitive marker of muscular damage. The peak of creatine phosphokinase level can be predictive for the development of acute renal failure because myoglobin level may return to normal within 6 hours after muscle injury. The peak of creatine phosphokinase (186.080 U/L; normal range 0-177) was recorded at 12 hours of admission. Other pertinent laboratory results such as urea, creatinine, prothrombin time, alanine aminotransferase and aspartate aminotransferase were also changed significantly. The peak of potassium level before dialysis was 6.8 mmol/L. Emergency fasciotomy of the anterior and posterior compartment syndrome was performed by a team of physicians after clinical examination. The second look debridement was performed at 48 and 72 hours. The plastic surgical procedure was performed 4 weeks later. On admission the patient also had oliguria with dark brown pigment in his urine. Arterial blood gases revealed metabolic and respiratory acidosis. The patient was hypovolemic and IV rehydratation with crystalloids, sodium bicarbonate and mannitol started immediately upon admission. Despite therapy his urine output decreased. Hemodialysis was initiated at serum potassium level of 6.8 mm/L and continued until his urine output returned to normal in three weeks. The patient was discharged from the hospital after six weeks, with normal urine output, without functional abnormality in his upper right limb. Acute rhabdomyolysis should be considered as a possibility in any patient with prolonged imobilization while in coma as well as in any intoxicated patient. Of course, creatine phosphokinase is the most sensitive indicator of muscle injury and the degree of creatine phosphokinase elevation correlates with the amount of muscle injury and disease severity. Other laboratory findings can help identify common complications of rhabdomyolysis such as acute renal failure, metabolic derangements and disseminated intravascular coagulopathy.

Molecular aspects of apoptosis

Abstract: Corresponding to its importance in cell count homeostasis in the body, apoptosis is a tightly regulated phenomenon. Both extracellular and intracellular molecules provide multiple regulatory and counter-regulatory pathways. Cell death is usually a response to the cell microenvironment, where the absence of certain factors (survival factors) or the presence of lethal factors promotes apoptosis. Surrounding cells, soluble mediators and the extracellular matrix regulate cell death and survival. Surrounding cells can synthesize survival or lethal factors. The intracellular regulation of apoptosis is also one of the forefront fields in biomedicine research. During the past five years, tremendous progress has been made in understanding apoptosis as a result of molecular identification of the key components of this intracellular suicide program. Biochemical activation of these key components of the cell death program is responsible for the morphological changes observed in apoptosis, including mitochondrial damage, nuclear membrane breakdown, DNA fragmentation, chromatin condensation and the formation of apoptotic bodies. Caspase activation plays a central role in the execution of apoptosis. Most caspases are constitutively expressed as inactive proenzymes (procaspases) in the cytosol and according to some reports in the mitohondria. Caspases are sequentially activated by proteolysis during apoptosis. In this review, we focus on the biochemical pathways that control caspase activation, particularly the activation pathways that are initiated by cell surface death receptors and mitochondria.

Use of complementary and alternative medicine among the patients in primary health care

Abstract: Objective Use of complementary and alternative medicine (CAM) is widespread in western countries despite its unconfirmed effectiveness. The aim of the study was to show the use of CAM by patients in primary health care. Patients and methods Cross-sectional method was used in a sample of 941 patients attending fourteen primary care practices from six Croatian cities who visited their family physician for whatever reason and filled in an anonymous questionnaire. On data analysis, distribution of frequencies and chi2-test were used. A probability value of p (two-tailed) indicated a statistically significant difference. Results The response rate was 70%. At least once in their lifetime CAM was utilized by 46% and in previous year by 32% of patients. Most frequent users were persons in the 46-55 age group years and those with higher education. A statistically significant difference was established between CAM utilization and age, education, employment and relaxation/stress reducing techniques. The most frequently used methods were herbalism (38%), homeopathy (15.6%) and acupuncture (13.1%). In 53.5% of subjects CAM was used together with conventional medicine. CAM was most often used for musculoskeletal diseases, gastrointestinal diseases, and for prevention. Chiropractic was most commonly used for musculoskeletal disorders, and herbalism and homeopathy for respiratory disorders. Supplements, natural healing products and homeopathic medicines were used by 80.1% of study subjects. Patients decide on the use of CAM because they believe it will help them (27%), conventional medicine failed to alleviate their complaints (19.7%) and they were afraid of side effects of drugs (13.3%). Satisfaction with CAM treatment was reported by 45.5% of study subjects. More than half of the patients notified their physician on the use of CAM (59.6%) and the majority (81.7%) of all subjects would like to discuss the use of CAM in their treatment with their family physician. Discussion In this study, the use of CAM was consistent with literature data. Frequent use of herbal method may lead to potential risks due to possible herb-drug interactions. The reason for the use of CAM is rarely dissatisfaction with their physician but often dissatisfaction with the results and side effects of conventional treatment. Doctors will require additional education on CAM methods, their effectiveness, safety, indications and contraindications in order to be well informed and able to discuss CAM use with their patients. Conclusion The use of CAM is common among patients attending primary health care. Sociodemographic factors are important predictors of its use. Doctors should openly ask their patients about the use of CAM and receive proper education to be able to discuss the potential benefits versus possible risks of its use in individual cases.

Clinical characteristics at onset of first febrile convulsions

Abstract: AIM: The aim of this retrospective study was to establish clinical characteristics of first febrile convulsions in children admitted to Department of Pediatrics in Tuzla, Bosnia and Herzegovina, and diagnosed with febrile convulsions in the period from January 1, 1999 till December 31, 2004. METHODS: Data were collected from medical records of the children admitted to Department of Pediatrics in Tuzla during the study period. The study included 716 medical records of children aged from one month to 7 years, analyzed for the following data: type of seizure (simple or complex), clinical manifestation of the convulsion (tonic-clonic, tonic, atonic, partial unilateral), body temperature after convulsion, and the length of convulsion. Of laboratory tests, the findings indicating possible infection and electroencephalogram (EEG) results were analyzed. Study subjects were divided into four age groups: 1-12 months (infants), 13 months to 2.9 years (young), 3 to 4.9 years (middle) and 5-7 years (older) groups. The chi2-test and Kruskal-Wallis test were used on testing statistical significance of between-group differences. The level of statistical significance was set at p < 0.05. RESULTS: Simple febrile convulsions were found in 88.8% and complex febrile convulsions in 11.2% of children (p = 0.0016). Tonic-clonic seizures were recorded in 90% and atonic in 8.6% of cases (p < 0.0001). Body temperature immediately after febrile convulsions ranged between 38 degrees C and 41.5 degrees C. Kruskal-Wallis test produced no statistically significant difference between the groups tested. Febrile convulsions lasted up to 5 minutes in 73.5% of cases, with the highest recorded in younger group (76.7%); 17.3% of children had seizures lasting between 6 and 10 minutes, mostly in older group (39%). Normal EEG findings were recorded in 96.9%, specifically altered findings in 1.4% and non-specifically altered findings in 1.7% of patients. DISCUSSION: The significantly higher prevalence of simple febrile convulsions as compared with complex forms and tonic-clonic seizure as the most common clinical manifestation of the attacks, recorded in the present study, were also confirmed in previous retrospective and prospective studies. It occurs with elevated body temperature above 38 degrees C. In the greatest proportion of children, it lasted for up to 15 minutes, and most children with febrile convulsions had normal EEG findings. CONCLUSION: Data on the clinical characteristics of first febrile convulsions in the Tuzla Canton, Bosnia and Herzegovina, recorded in the present study, may prove useful on planning the programs of pediatric health care in the region.

Temporomandibular disorders and headaches

Abstract: Temporomandibular disorder (TMD) is a common name for a series of pathologic conditions with similar signs and symptoms, which can lead to a disturbed and altered function of the stomatognathic system. Most of these conditions are of a multifactorial etiology, which can pose difficulties in obtaining a precise and accurate diagnosis. However, TMD is an ever more common and serious problem in contemporary dental practice and at general medical offices, so a more systematic approach in its diagnosis including data collection and interpretation is necessary. Accordingly, accurate diagnosis of TMD requires proper identification and classification of the dysfunction, as well as recognition of the mechanism and origin of pain occurrence.

Evidence based guidelines for the treatment of primary headaches

Abstract: Some patients suffering from headache require neurologic examination. The objective of the guidelines for the treatment of headaches is to help physicians in their daily care for headache patients. In most patients, the diagnosis of migraine has not been made by a physician and they have not received appropriate care to treat migraine attacks. New therapeutic methods (for acute and preventive treatment) have been introduced in the past fifteen years. Triptans should be offered to patients that fail to respond to usual analgesics, those with moderate to severe migraine in particular. Depending on comorbidity, preventive therapy should be recommended to individuals with frequent or prolonged migraine attacks. In patients with tension headaches, organic causes underlying the headache should be ruled out, while the treatment includes pharmacological and non-pharmacological measures. Although rare, patients with cluster headaches suffer severe pain; oxygen inhalation or triptans are recommended for acute attack, and preventive therapy may be indicated in some cases. The guidelines provide classification, diagnostic criteria and therapeutic principles for primary headaches. All recommendations listed in the guidelines are based on meta-analyses and recommendations from the world literature, with special reference to therapeutic options available in Croatia.

Surgical or biologic sphincterotomy in the treatment of chronic anal fissure

Abstract: Background Chronic anal fissure is a lineal ulcer of the lower part of the anal canal. It is a painful condition characterized by postdefecational pain and bleeding. It is associated with internal anal sphincter spasm. The relief of internal anal sphincter spasm is the key for providing fissure healing. Gold standard in the treatment of chronic anal fissure is partial lateral internal anal sphincterotomy. Methods Sixty patients with chronic anal fissure were randomly assigned into two groups treated either by surgical sphincterotomy or injections of botulinum toxin into internal anal sphincter. Manometric measurements were performed before and three months after treatment. Follow up period was six months. The aim of the study was to compare results between these two groups. Results Both methods efficiently reduced resting anal pressure and successfully healed chronic anal fissure. Conclusion Surgical and biologic sphincterotomy are almost equally effective in the treatment of chronic anal fissure. Injecting botulinum toxin into internal anal sphincter is a safe, easy to apply and effective method in the management of anal fissure.

Neurophysiological methods in headache diagnosis

Abstract: Neurophysiological methods used in the diagnosis of headache, especially migraine are: electroencephalography (EEG), evoked cortical potentials (VEP, BAER, ERP), reflex responses, autonomic tests and transcranial magnetic stimulation (TMS). Interpretation of EEG can be important for the differential diagnosis of some disorders with headache as a presenting symptom. Noninvasiveness, accessibility and ability to repeat the test due to exposure to harmful ionization are the main advantages of EEG. The role of thorough medical history and clinical assessment in patients with headache should not be underestimated. Interictal EEG (between headache attacks) is not significant in routine evaluation of these patients, but can be useful in patients with unusual symptoms suggesting epilepsy or migraine. It is indicated in patients with an abrupt onset of headache, in patients with migraine followed by neurological signs, in basilar migraine, migraine with extended duration of aura and in cases where epilepsy is suspected. Headache as a symptom is present in various brain and systemic diseases and metabolic disorders. EEG changes seen in headache patients are not specific for a particular disorder, but can suggest additional evaluation and accelerate accurate diagnosis and earlier treatment. Visual evoked cortical potentials (VEP) and cognitive evoked potentials (ERP) in patients with migraine in interictal periods have shown differences in sensory processing between patients with headache and healthy controls. Neurophysiological methods (VEP, ERP) between migraine attacks show cortical hyperactivity and predisposition for further attacks. Brainstem auditory evoked responses (BAER) are a sensitive method for the detection of central nervous system damage. Activation of the brainstem during the migraine attack results in an amplitude increment seen soon after the end of the attack. According to recent studies, R2 component of the blink reflex was six times longer during migraine attack as compared to interictal values. This is thought to be a response to sensitization of the skin nociceptive afferent arch or other neurons in the trigeminal nucleus. In patients with cluster headache, autonomic tests generate cardiovascular and pupillary response suggesting systemic sympathetic hyperactivation connected to concurrent pupillary sympathetic hypofunction and modified opioid modulation. TMS is shown to be very useful for the detection of pathophysiological changes of numerous disorders including migraine, due to its excitatory and inhibitory effects. Recent studies have shown changes in motor and occipital cortex during TMS interictal excitability. Neurophysiological tests are used in differential diagnosis of headache, follow up of possible complications in patients with symptomatic headache as well as in neurorehabilitation. In addition, electrophysiological diagnostic test can contribute to better understand the headache pathophysiology.

[Headache caused by pesticides--a review of the literature].

Abstract: Headache makes one of the most common side effects of frequently pesticide application. This is to be taken care of in rural areas. Headaches have been reported with the use of ivermectin, ivermectin-diethylcarbamazine, organophosphates, and also with the fungicide maneb and copper sulfate, carbofuran, hexonal, dioxin, methomyl and its salts, as well as rare cases of poisoning with the fungicide combination of propineb and cymoxanil. Headache often occurs after long term work with pesticides and/or in laboratories. There are numerous symptoms accompanying headache in pesticide poisoning the most common being elevated body temperature, lassitude, dizziness, irritability, nausea, vomiting, epigastric pain, diarrhea, myalgia, pains in the arms and legs, sleepiness, pains in joints, irritation of eyes/face/skin, sweating. Much less common are respiratory disturbances, tachycardia, tachypnea and other cardiac distur bances, fall of blood pressure, gastrointestinal discomforts, constipation, poor appetite, significant decrease in leukocyte count, anemia, albuminuria, azotemia, fasciculations, miosis, blurred vision, memory disturbances and other neurologic disturbances, postural tremor, signs of cerebral function damage, bradykinesia, etc.

[Airplane headaches--two new cases and a review of the literature].

Abstract: We present two new cases of airplane headache and compare them with 13 cases described so far. The two new cases refer to a man and a woman, one each. The woman suffered from headache during the take off and throughout the flight, which is rarely encountered. The man had a typical airplane headache with accompanying symptoms, with the feeling of pressure in the left side of the head. Diagnostic treatment revealed no pathomorphological substrate of the condition. The etiology and pathophysiology of this type of headache have not yet been fully clarified. We presume that this type of headache may be connected with changes in the nasal mucous membrane with deviation of the nasal septum, as well as in ethmoidal sinuses and other paranasal cavities. The rise of atmospheric pressure in the airplane and barotrauma from activation of the trigeminovascular system certainly play a major role in the occurrence of this headache.

[Ambulatory blood pressure monitoring in children and adolescents--our results].

Abstract: UNLABELLED Objective of the study was to present the results of ambulatory blood pressure monitoring (ABPM) in children and adolescents with hypertension diagnosed by primary care physician. METHODS we retrospectively reviewed ABPM studies in 76 children. Mean patient age was 14.3 years (4-17 years); 53 boys (69.7%) and 23 girls (30.3%). Children were classified as having either primary or secondary hypertension following a standardised evaluation. According to ABPM data hypertension was defined as mean blood pressure greater than 95 th percentile for age, gender and height and/or blood pressure load (BP load) greater than 25 percent. RESULTS In 16 (21.1%) children the ABPM studies were normal, leading to a diagnosis of "white coat hypertension" (WCH). Among 50 (65.8%) children with primary hypertension the most (20 or 40% children) had stage 3 hypertension. In secondary hypertension group 6 (60%) of children had stage 3 hypertension. Daytime and nocturnal systolic and diastolic blood pressure values were greater in patients with secondary hypertension compared with patients with primary hypertension. DISCUSSION The oscillometric monitors for ABPM are generally preferred in children. The high percentage of stage 3 hypertension in both primary and secondary hypertension can be partly explained with normative values used witch were those recommended by consensus group such as the Second Task Force. Daytime and nocturnal systolic and diastolic blood pressure values greater in patients with secondary hypertension correspond to data in literature. CONCLUSIONS ABPM is important tool in the evaluation and management of childhood hypertension. A normotension in ABPM study will suggest WCH. According toABPM results it is possible to classify hypertension, to identify children who require more detailed evaluation and to asses the efficacy of antihypertensive treatment. The lack of consensus and generaly accepted normative data for pediatric population in ABPM interpretation require further investigation.

Pseudoaneurysm after renal transplantation

Abstract: Pseudoaneurizma je rijetka komplikacija s cestim gubitkomtransplantata Pojavila se u troje nasih bolesnika U prvog je otkrivena mjesec i pol nakon zahvata na termino-terminalnoj anastomozi gornje renalne s internom ilijacnom arterijom Pseudoaneurizma je resecirana, ali je ledirana uretero-ureteralna anastomoza s posljedicom gubitka transplantata Drugom bolesniku su dvije renalne arterije s aortalnim patchom zasebno anastomozirane na vanjsku ilijacnu arteriju Dva i pol mjeseca bolesnik je primljen zbog porasta kreatinina i hipertenzije Obradom je otkrivena pseudoaneurizma uz anastomozu gornje renalne arterije s oslabljenom cirkulacijom u pripadajucem dijelu bubregaNa kiruskoj intervenciji rekonstrukcija je izvrsena graftom vene safeneizmeđu interne ilijacne arterije i reanalne arterije Otvor na eksternoj ilijacnoj arterijizatvoren je patchom vene safene Tri i pol mjeseca kasnije hitno je primljen zbog bolova u zdjelici Doplerom je otkrivena pseudoaneurizma 6x7 cm medijalno od transplantata na intervenciji istog dana zbog znacajnog ostecenja zamjenili smo eksternu ilijacnu arteriju Goretex protezom 6 mm Donju bubrežnu arteriju nismo uspjeli spasiti Stanje pacijenta je dobro uz dobru funkciju transplantata trecem bolesniku je pseudoaneurizma otkrivena Doplerom 15 mjeseci od zahvata Zbog uredne cirkulacije u bubregu i male vjerojatnosti uspjesnog operacijskog rjesavanja odlucili smo se za pracenje Promjer pseudoaneurizme se smanjio od 34 na 26 mm

The cardiorenal syndrome and erythropoietin

Abstract: The pathophysiological condition, in which combined cardiac and renal dysfunction amplifies a progression in the failure of the individual organ, has been denoted as severe cardiorenal syndrome (SCRS). An interactive network of cardiorenal connectors, i.e., the renin-angiotensin system (RAS), nitric oxide (NO) and reactive oxygen species (ROS) balance, the sympathetic nervous system (SNS), and inflammation, has been proposed as the cornerstones of the pathophysiology of SCRS. Because erythropoietin (Epo) production declinesin chronic renal failure (CRF) and Epo sensitivity might decrease by the cardiorenalconnectors in patients with the SCRS, it is not surprising thatanaemia is a commonly occurring state coinciding with CRF and chronic heart failure (CHF). Epo treatment in patients with SCRS acts via haematopoietic effects, but also may intervenes in the vicious circle of cardiorenal connectors with subsequent deteriorating effects on cardiac, renal, and vascular function. It appears that regular Epo treatment in anaemic patients with diminished renal function improves cardiac performance, delays the progression of kidney disease, and may be of clinical benefit even to patients suffering from CHF with relatively mild anaemia. Despite growing evidence about Epo having positive effects on both renal and cardiac function, little is known about the underlying mechanisms of action.

The role of patient compliance in the management of glaucoma

Abstract: AIM The aim of the study was to evaluate patient cooperation in glaucoma treatment METHODS We evaluated data collected by an anonymous questionnare from 98 glaucoma patients who answered 6 questions regarding their compliance and persistence in glaucoma treatment RESULTS Study results revealed 50% of patients to fail taking their antiglaucoma therapy regularly Patients on monotherapy showed better compliance and higher level of satisfaction with treatment than those on combination antiglaucoma therapy consisting of 2 or 3 eyedrops Discontinuation of persistence was recorded in 31% of patients, whereas 51% of patients did not present for control visits every six months as suggested by their ophthalmologist CONCLUSION Patients are more compliant and persistent with antiglaucoma monotherapy than with combined therapy Greater compliance and persistence with ocular hypotensive therapy may improve the outcomes in glaucoma

[Tension-type headaches].

Abstract: Tension-type headache is one of the most common and most significant primary headaches. Tension-type headache is a very heterogeneous disorder. It can be divided into episodic and chronic tension-type headache. The pain is a dull, pressing, tightening, typically band-like sensation. The pain is of non-pulsating quality, the location is bilateral, and there is no nausea, vomiting, phonophobia or photophobia. There are no prodromal symptoms or aura. The pain is mild to moderate and it does not aggravate with routine physical activities. Some patients have increased tenderness of pericranial muscles. Psychological factors are common in tension-type headache. Nitric oxide has an important role in the pathophysiology of chronic tension-type headache. Probably it promotes central sensitization and therefore increases nociception. In differential diagnosis of tension type-headache, all structural and metabolic diseases causing headache have to be ruled out, as well as all other primary headaches. All comorbid and coexistent states should also be considered. In the treatment of tension-type headache, pharmacological and non-pharmacological methods are employed. Analgesics, myorelaxants, anxiolytics and antidepressants are most commonly used, as well as physical therapy, massage, acupuncture, behavioral therapy and psychotherapy. Recently, the applications of botulinum toxin and acupuncture have been described in the treatment and prophylaxis of tension-type headache.

[Amusia and aphasia of Bolero's creator--influence of the right hemisphere on music].

Abstract: Objectives The experience with cortical localization (BA 44, 45, 22) of language (Broca, Wernicke and others) in the left hemisphere has been repeatedly tested over the last 150 years and is now generally accepted. A single case report with autopsy findings (Leborgne, Tan tan), has enabled to localize the seat of spoken language in the left third frontal convolution. As music and language have a lot in common and even share the same hearing system, it is logical to try to localize the cognitive centers for music too. Methods The disabling neurological disease illness of Maurice Ravel (1875-1937), a French impressionist composer, is not the right example to localize music center as that of Broca's language center, but it demonstrates the role of the right hemisphere in music production. In the last five years of his life, Ravel suffered from an unknown disease that affected the left hemisphere causing aphasia, apraxia, alexia, agraphia and amusia. It was the reason why Ravel could not compose during the last years of his life. In contrast to Ravel, Shebalin and Britten continued writing music works of their own although aphasic after having sustained two strokes to the left hemisphere. While lacking clinical cases with selective ablative brain lesions, research into the music localization can be done using modern imaging technologies such as fMRI and PET. Results Exercising music (professionally) develops analytical process in the left hemisphere whereas other individuals process music in their right hemisphere. There is right ear (left hemisphere) predominance in musicians and vice versa in musical amateurs. Music lateralization towards the right hemisphere is seen in women and in inattentive listeners. It can be subject to cultural influence, so the Japanese process their traditional popular music in the left hemisphere, whereas Westerners process the same music in the right hemisphere. Music and language are processed separately; they are localized in homologous regions of the opposite hemispheres. In 1937, Ravel underwent neurosurgical procedure performed by Vincent; autopsy was not done. It is believed that the cause of hi disease was primary progressive aphasia associated with Pick's disease. Conclusion Bolero and Concerto for the Left Hand were the last Ravel's works (the onset of his disease), so it is possible that the projected the influence of the healthy right hemisphere onto his music (and on the creative process) because Ravel's left hemispher was damaged. Indeed, in these last music works one can feel the predominance of changes in pitch (timbre), i. e. right hemisphere, in comparison to only few changes of melody (left hemisphere).

Biphenotypic and bilineal acute leukemias

Abstract: Human acute leukemias (AL) are classified as myeloid or lymphoid according to cytomorphology and the expression of leukocyte differentiation antigens/CD-markers. However, in the minority of cases leukemic cells express markers of more than one lineage, which has led to the introduction of a new subgroup of acute leukemias termed mixed or biphenotypic acute leukemias (BAL). In an effort to distinguish between BAL and those AL with aberrant expression of markers of other lineage, the European Group for the Immunological Characterization of Acute Leukemias (EGIL) has proposed a scoring system in which CD-markers are assigned a score of 0.5, 1.0 or 2.0, depending on the specificity of a particular antigen for myeloid, B- and/or T-lymphoid lineage, respectively. The new WHO classification of hematologic tumors has adopted the EGIL criteria for BAL and introduced a new group of AL termed 'AL of ambiguous lineage'. In addition to BAL in which a single cell population expresses both myeloid and lymphoid differentiation markers, this new group of leukemias also comprises cases that present with two separate blast populations (acute bilineal leukemia, aBLL). In general, BAL accounts for less than 5% of all AL cases, whereas aBLL is a rare disease constituting 1%-2% of AL cases that contains B- or T-lymphoid along with myeloid blasts. Chromosome abnormalities are frequent in both entities with a relatively high incidence of Philadelphia chromosome and rearrangements involving 11q23, especially in cases with B- and myeloid involvement. Other biological features include CD34 expression and multi-drug resistance P-glycoprotein overexpression. The prognosis of BAL and aBLL is unfavorable, with poor prognostic factors being age, high WBC and the presence of Philadelphia chromosome. Unfortunately, optimal therapy is not known, although regimens designed for acute lymphoblastic leukemia may result in a better response rate. Collaborative studies are needed for better understanding of the biology of these entities and establishment of standard therapeutic protocols.

Neurological complications in renal transplant recipients

Abstract: Renal transplantation is method of choice for treatment of patients with end-stage renal disease without contraindications for immunosuppressive therapy. Neurological complications occur frequently in renal transplant recipients. They may be the consequence of immunosuppressive treatment, but more often evolve as the consequence of previous disturbances which developed during the state of uraemia and treatment with dialysis. The most pronounced neurotoxic effect has calcineurin inhibitors tacrolimus and cyclosporine. The spectrum of neurological disturbances caused by calcineurin inhibitors range from very mild symptoms as paraesthesiae, tremor, headache or flushing, to severe changes that may cause lethal outcome. Peripheral neuropathies in renal transplant recipients may occur in the form of mononeuropathy or polyneuropathy. Cerebrovascular diseases are consequence of changes on blood vessels caused by uraemia, dialysis and side effects of immunosuppressive drugs. They cause death in 8% of renal transplant recipients. Central nervous system (CNS) infections usually occur during the first posttransplant year. Unclear symptomatology frequently postpones the diagnosis. Diagnostic evaluation should include magnetic resonance imaging for localization of the process, as well as lumbal puncture in cases without contraindications for the procedure, in order to determine the causative agent. Regarding the ominous prognosis of CNS infections in the immunocompromised host, only timely diagnosis may improve survival. The most common causative agents are Cryptococcus neoformans, Listeria monocytogenes and Aspergillus funigatus. Viral infections also occur, and are commonly caused by herpes virideae, varicella-zoster virus and papova virus. CNS infections clinically present as meningitis, progressive dementia or focal neurological defect. The most common primary brain tumors are B-cell lymphomas, but glioblastoma, hemangioblastoma, leiomyosarcoma or glioma may also occur. In cases of neurological posttransplant complications, optimal treatment should be guided by neurologist, nephrologist and infectologist, in some cases also by neurosurgeons.

[Electrosurgery, the cornerstone of current achievements of brain tumor surgery--on the occasion of 80th anniversary].

Abstract: Neurosurgical pioneers had so many obstacles that prevented safe work and favorable outcome of the patients operated on. The mortality rate was high and discouraging. The operations were fast and rude whereafter the patients were dying or suffered prolonged hemorrhagic shock. The three cornerstones of neurosurgery, i. e. cerebral localization, asepsis and narcosis, had not yet been discovered and the only diagnostic tools available were recently discovered x- rays, ventriculography and angiography. However, the greatest challenge for the neurosurgeon was that even if luckily localized through a craniotomy, how to remove the brain tumor while avoiding uncontrollable bleeding. Therefore, an array of techniques and tricks were developed such as bone wax, Cushing silver clips, packing of the wound, etc. but all of them were insufficient in case of intracerebral hemostasis. Electrosurgery revolutionized this unacceptable situation thoroughly. It was introduced in neurosurgery 80 years ago (on October 1, 1926) by great Cushing, whereupon its usage has spread rapidly worldwide. The mortality rate was lowered to 13%! The coagulator was constructed by Harvard's physicist Bovie, after whom is named. Owing to the new technique, the control of bleeding in neurosurgery has become much safer, craniotomies are larger than before and the operation time is esentially longer. Since the perfection of bipolar coagulation (by Greenwood and Malis brothers), and after the introduction of the operating microscope (Donaghy, Krayenbuhl, Yasargil) in 1970, this half of a century-long monopolar era was over, and the new time of microneurosurgery has begun. It enables better, easier and more precise hemostasis of the magnified brain blood vessels (microscope).

Recommendations for Treatment of Neuropathic Pain

Abstract: Tricyclic antidepressants (TCAs), selective serotonin and norepinephrine reuptake inibitors (SSNRIs), calcium channel alpha2-delta ligands and topical lidocaine are recommended as a first-line treatment for patients with neuropathic pain. In patients who have failed to respond to these first-line medications alone or in combination, opioid analgetics or tramadol can be used as a second-line treatment alone or in combination with one of the first-line medications. In some specific situations, opioid analgetics or tramadol can also be considered for first-line use.

The role of clinical and metabolic factors in the genesis and development of diabetic retinopathy

Abstract: AIM Diabetes is a complex polygenic, auto-aggressive disease caused by many different factors. Diabetic retinopathy is the leading cause of new cases of blindness in people aged between 25 and 65 years (working population) in industrialized countries. The aim was to determine whether disease duration, diabetes type and blood concentrations of some metabolites may be risk factors for the genesis and development of diabetic retinopathy. METHODS This retrospective study included 402 diabetic patients from the Split-Dalmatia County. Laboratory testing included blood glucose, glycosylated hemoglobin A1c, total cholesterol, HDL and LDL cholesterol fractions, and apolipoprotein A and B concentrations. DISCUSSION The incidence of diabetic retinopathy is increasing in our region, with nonproliferative form as the most common type. Women suffer more frequently from diabetic retinopathy, those aged 60 being at the highest risk. The genesis of diabetic retinopathy is directly correlated with the type and duration of diabetes. Changes in total cholesterol concentration, especially LDL fraction, and apolipoproteins A and B (especially B) indicate an increased relative risk of developing diabetic retinopathy. CONCLUSION In our opinion, testing of glycosylated hemoglobin, HDL and LDL cholesterol fractions, and apolipoproteins A and B in the standard follow-up protocol for diabetic patients would significantly contribute to the prevention and reduction of diabetic retinopathy as the most common and most difficult diabetic eye complication.

Pain and ischemic symptoms in craniocervical artery dissection

Abstract: Arterial dissections of craniocervical arteries are being increasingly identified due to the growing awareness of the clinical picture and advances in imaging technologies. During a one-year period, we observed 20 patients with craniocervical artery dissection at cerebrovascular laboratory. Clinical picture, localization of the dissection and follow up studies were analyzed. Twenty study patients were divided into four groups: in group 1, all 4 patients with common carotid dissection with or without aortic dissection presented with pain; in group 2 with internal carotid dissection, pain was present in 5 out of 11 patients, ischemic symptoms in all 11 patients, and Horner syndrome or lower cranial nerve palsies in 3 of 11 patients; in group 3, all 4 patients with dissecting plaque were free from pain but had ischemic symptoms; and in group 4 there was only one patient with isolated vertebral artery dissection who had no pain but presented with stroke. Pain was the most prominent symptom in patients with lower craniocervical artery dissection. Ultrasound enabled follow up of the dissection.

Metric analysis of temporomandibular joint in asymptomatic persons by magnetic resonance imaging

Abstract: Cilj istraživanja bio je utvrditi položaj, odnosno anteriorni pomak zglobne plocice u klinicki odabranoj skupini asimptomatskih osoba (25 studenata stomatologije u dobi od 21 do 27 godina, prosjecno 23, 4 godine, od toga 72% ženskog spola) bez simptoma i znakova temporomandibularnih poremecaja te kvantitativno ga usporediti sa položajem glavice kondila u položaju zatvorenih usta. Metricka analiza temporomandibularnih zglobova provedena je pomocu magnetske rezonancije na T1 mjerenim snimakama u parasagitalnoj ravnini. Utvrđena je prevalencija anteriornog pomaka zglobne plocice kod 20% osoba, odnosno 25% njihovih temporomandibularnih zglobova. Metrickom analizom potvrđen je vizualno utvrđen anteriorni pomak zglobne plocice, ali relativni položaj kondila ne ovisi o skupinama zglobova asimptomatskih ispitanika s fizioloskim položajem i anteriornim pomakom zglobne plocice. Aim: The objective of this study was to investigate prevalence of anterior disc displacement and condyle position in volunteers free from clinical symptoms and signs of temporomandibular disorders. Material and Methods: Bilateral parasagittal T1-weighted magnetic resonance images of temporomandibular joints (TMJ) in 25 asymptomatic volunteers (mean age 21– 27, average 23.4 years, 18 (72%) female and 7 (28%) male) were analyzed and metric measurement of disc and condyle position were investigated. The metric analysis of the position and relationship between the disc and the condyles was described using Kurita et al’ s method of measuring the relative and absolute distances of reference points. In statistical data analysis, the left and right TMJs of each person were presented as two separate entities within the data analysis. The nonparametric statistics was used. Results: Anterior disc displacement was found in 5 (20%) of asymptomatic volunteers (four of them female). Anterior displacement with unilateral reduction and anterior displacement without reduction unilaterally was present in two subjects each, whereas one volunteer had anterior displacement without reduction bilaterally. There was no difference between in the calculated position of condyle between joint with and without disc displacement (Kruskal-Wallis test, p<0.05). Discussion: This study evaluated prevalence of asymptomatic anterior disc displacement in symptom-free healthy volunteers and the position of the condyle in the glenoid fossa. Displaced disc is the main cause of temporomandibular pain ; however, studies in asymptomatic volunteers also suggest it to be an anatomic variant. The relationship between dorsocranially positioned condyle and anterior displaced temporomandibular joint disc is a controversial issue. Metric analyses were made only in the parasagittale plane. Conclusion: There was difference between the calculated position of disc between joint with no disc displacement and joint with disc displacement, but this study found no difference in the calculated condyle positions according to the presence or absence of disc displacement.

[Surgical treatment of lower jaw pseudoarthrosis as a result of fracture non-treatment following tooth extraction].

Abstract: Fracture of the lower jaw following tooth extraction is a rare and severe complication, occurring most often in the preangular region following third molar extraction. When left untreated, pseudoarthrosis can occur. Symptoms show a wide variance, including pathologic mobility, pain and infection, as well as sometimes trismus before and following surgical treatment. The possible complications of pseudoarthrosis may be malnutrition, jaw deformity and long-term disability. Treatment options range from prescription of a soft diet in case of simple fracture to surgical treatment by open reduction and internal fixation. A case is presented where a 47-year-old male suffered from painful perimandibular swelling and complained of "instability" of the lower jaw as well as hypoesthesia in the area of the left mental nerve. Case history revealed that he had had extraction of the lower left second molar (tooth 37) four months before. Following clinical and radiographic examination he was diagnosed with non-diagnosed and/or non-treated lower jaw fracture. The patient was surgically treated using an oseosynthetic plate to ensure stability. The postoperative protocol showed satisfactory results. Bone growth in the fracture line was recorded in the follow up. However, due to the four-month period of pseudoarthrosis and infection, the plate was removed much later than it would have been the case if surgical treatment had been performed immediately following the fracture. The delayed diagnosis of this fracture demonstrates the necessity of radiologic control when a fracture is suspected following tooth extraction. When a patient shows symptoms inconsistent with those following tooth extraction, surgical consultation is recommended.

Causes of climatic changes and their consequences on human health

Abstract: Environmental disasters are common phenomena caused by human factors. Disaster episodes may be the result of climatic changes such as global warming, which can lead to floods or drought. Greenhouse gases, and especially the ozone, represent a special problem. Atmospheric pollutions are the result of fire, storm dusts, winds, acid rain, etc. Underwater earthquakes very often end in tsunami with waves of up to 30 meters. Disasters described in the territory of Croatia include atmospheric pollutions, fires, floods, and droughts. All disasters affect the health of the population, particularly of the elderly. This most often includes the cardiovascular and respiratory systems, allergic reactions, and carcinogenic effects, resulting in increased mortality.

Clinical and laboratory prognostic parameters for leukemic types of chronic lymphoproliferative diseases

Abstract: AIM: The aim of the study was to identify the clinical and laboratory (hematologic, biochemical and morphological) prognostic parameters of chronic leukemic lymphoproliferative diseases (CLLPD) METHODS: The study included 155 CLLPD patients Analysis was performed in the overall CLLPD population and separately in a subgroup of patients with B chronic lymphocytic leukemia with variants (B-CLL+V) including typical B chronic lymphocytic leukemia (B-CLL), mixed chronic lymphocytic leukemia and prolymphocytic leukemia (CLL/PLL), and a variant of chronic lymphocytic leukemia with lymphoplasmocytoid differentiation (CLL/IMC) Kaplan-Meier method (Statistica 71) was used on survival analysis RESULTS: Male patients older than 62 (p=003991), female patients (p=002871), patients not receiving antitumor therapy on study entry (p=001902) and patients not treated for CLLPB upon study entry (p=004076) showed better survival rate Older patient predominated in the group requiring no antitumor therapy (p=0019247) Analyis of sex distribution yielded an equal male to female ratio in the overall CLLPD population and B-CLL+V subgroup Mann-Whitney U-test was used to assess the clinical significance of quantitative parameters related to patient age and sex The level of bilirubin, the size of cervical lymph nodes and doubling of peripheral blood lymphocytosis (DTL) were lower in the group of older patients (>60 years) Men had higher levels of hemoglobin, bilirubin, SGOT and creatinine, and larger spleen and liver Statistically significant survival differences were recorded for 16 of 20 clinical parameters Patients older than 60, female patients and patients receiving no antitumor therapy showed better survival Lower clinical stage according to Rai and Binet and total tumor mass (TTM) lower than 9 indicated better prognosis, whereas patients with spleen enlargement and multiple regions involved with lymph node enlargement showed poorer survival B-CLL+V patients and patients free from doubling of total tumor (DTM) or of absolute lymphocyte count (DTL) within 12 months had better survival than the overall CLLPD patient population A statistically significant survival difference was recorded for 5 of 15 bone marrow (BM) parameters tested: normal and less cellular BM puncture specimen, >70% of all lymphatic cells, >16% of atypical lymphatic cells, and >18% of granulocytes in myelogram indicated better prognosis Poorer disease outcome was associated with interstitial and nodular infiltration found on bone biopsy Ten of 20 hematologic parameters were found to be statistically significant Poorer prognosis was associated with red blood cell count 100 x 10(9)/L, reticulocyte count >5/10(3) E, hemoglobin 51% monocytes and >101% granulocytes in differential blood count Statistically significant survival differences were found for 10 of 20 biochemical parameters tested Poorer survival was recorded in patients with LDH >300 U/L, SGOT >24 U/L, calcium <23 mmol/L, total protein <661 g/L, albumin <40 g/L, alpha2 globulin<59 g/L, beta globulin <73 g/L, y globulin <9 g/L and IgG <10 g/L Better prognosis was only indicated by lower levels of IgM (<091 g/L) CONCLUSION: Careful clinical examination is an important step on assessing the extent and progression of the disease, and a major chain on tailoring individualized therapeutic approach, along with clinical stages according to Rai and Binet, CLLPD subtype and progression factors (DTM and DTL) Laboratory parameters (hematologic and biochemical) as objective quantitative parameters obtained by simple venipuncture, in contrast to the 'researcher-dependent' ones, increase the utilization of some of these parameters as risk factors in CLL

[Hip fracture--personal, family and social problem of the third age].

Abstract: AIM: The percentage of elderly people increases in societies today and so does the number of specific conditions, illnesses and injuries, with hip fracture as the most important one. The aim of the study was to point to hip fracture as a medical and social problem by objectively quantifying functional abilities of geriatric patients after hip fracture. PATIENTS AND METHODS: The study included 414 (63 male and 351 female) with femoral neck fracture and hip endoprosthesis implanted at University Department of Traumatology in Ljubljana during the 1988-2004 period. Data on sex distribution, concomitant diseases, complications, estimation of functionality before injury, and dynamic and final level of functional recovery were collected. RESULTS: The patient mean age was 77 +/- 7.3 (range 28-96) years. Excellent mobility before injury, according to personal report, was recorded in 322 (77.78%), good mobility in 78 (18.84%) and poor mobility in only 14 (3.38%) patients. The mean dynamics of functional recovery was as follows: independent sitting at 2 days, standing at 3.6 days, and walking at 7 days of the surgery. At the end of rehabilitation, an average patient felt periodic pain that did not affect his/her activities, could walk without problems at least one kilometer, limped to a certain degree, used a cane, could climb stairs holding a handrail, sat in the chair for a long time, put on shoes and socks with minor difficulties, used public transportation and had no significant deformity of the hip. With that level of functionality, our patients were independent in daily activities, able to stay socially integrated, and other people's help was reduced to the minimum. DISCUSSION: The patient's functionality before injury, the duration and quality of rehabilitation after surgery, and the patient's motivation and cooperation during rehabilitation are the key factors of patient recovery to the pre-injury state. In spite of numerous concomitant diseases, reduced psychophysical abilities of the elderly and medical difficulties in the management of these injuries, such treatment of hip fractures is necessary and human for patients and time-consuming for medical staff, yet being the most profitable option for the society. Hip fracture and consequential disablement cause a double problem. On the one hand, it entails dependence on other person, family or social institution, or society in general, and on the other hand there is mental frustration, especially if he/she is psychically instable. Quite frequently, disabled persons have psychical traumas that have unfavorable impact on their families. It is additionally complicated in societies that tend to stigmatization of disabled persons. Therefore, it is very important how the society will behave toward disabled elderly who are generally more vulnerable. Language: hr

Cytomorphological characteristics of thyroid papillary carcinoma and their prognostic value

Abstract: OBJECTIVE: The aim of this study was to determine cytomorphological characteristics of classic papillary carcinoma that could point to a higher likelihood of intraglandular or paraglandular dissemination of the disease. METHODS: Morphological characteristics of classic thyroid papillary carcinoma and the size and ultrasonography characteristics of thyroid nodules were semiquantitatively analyzed in 100 patients diagnosed with papillary carcinoma by cytology and verified by histology. Data on the presence of intraglandular and paraglandular dissemination, established by histologic examination of postoperative material, were collected and analyzed. RESULTS: There were 16 male and 84 female patients aged 4-78 (mean 48.8) years. Polymorphism, multinucleation, intranuclear inclusions, psammoma bodies, presence of follicles, Hurthle like cells and connective tissue elements were present in 31%, 62%, 88%, 19%, 16%, 26%, 10% of cases, respectively. Thyroid nodule size was 4-80 mm (mean 14.5 mm) and up to 10 mm in 50% of cases; 76% of nodules were hypoechoic, 96% had irregular margins, and calcifications were present in 71% of nodules. Intraglandular dissemination and neck lymph node metastases were found in 16% of patients. Paraglandular dissemination was observed in 15% of cases. Statistical analysis showed no significant cytologic characteristic that would imply a higher or lower likelihood of intraglandular dissemination. Older age was found to be a risk factor for paraglandular but not intraglandular dissemination, while nodule size and neck lymph node metastases were not important for the presence of intraglandular or paraglandular dissemination. CONCLUSION: Since no marker that could indicate a higher or lower likelihood of intraglandular and/or paraglandular dissemination of thyroid papillary carcinoma has yet been identified, it is advisable to perform total thyroidectomy when papillary carcinoma is diagnosed by cytologic examination, irrespective of the nodule size or tumor subtype.